Working with Diagnoses

Adding a Diagnosis to your chart

Adding a new diagnosis to your chart is as simple as adding a diagnosis section to your chart’s Assessment page, and then selection from a list of diagnoses.  OutSmart has 3 diagnoses libraries:

1. Basic diagnoses: Just the diagnosis text, in clear and direct wording.  For example, ‘Hypertension”, or “Cluster Headaches”.
2. Traditional Chinese Medicine (TCM) diagnoses
3. ICD-10 international diagnoses. These are mainly used in cases where medical insurance is involved and required specific ICD-10 codes to be used.

All three of these libraries are available from the same drop down menu when adding a diagnosis.  To add a diagnosis to your chart, click on the green ‘+A’ button at the top left of the chart editing interface.  This will open up a menu of various sections you can add to your Assessment.  Select ‘Diagnosis’ from that list.  This will add a diagnosis section to your SOAP chart, in the Assessment page.

Adding a diagnoses section to your SOAP chart

Once the section has been added, you can select a diagnoses from the first drop-down menu at the top left of the section.  This is the diagnosis list.  Start typing in the diagnoses you are looking for, and the list will start filtering and showing results that match your search term.  Once you find what you are looking for, click on it to add it to your chart.  Note that diagnoses with the yellow ‘DX’ label indicate standard diagnoses, the ‘TCM’ label indicate TCM diagnoses, and the ‘ICD’ label indicate ICD-10 codes.

All three ‘standard’, ‘TCM’, and ‘ICD’ diagnosis libraries can be found in the same searchable menu.

Differential Diagnoses

Once you select your working diagnosis, you can then add differential diagnoses (DDX) in the same manner, using the 2nd diagnosis drop down menu in the section, labelled ‘Select DDX’.

Making a diagnosis billable

Once selected, a diagnosis is by default marked as non-billable.  This means that you do not intend for this diagnoses to be indicated on the patient’s invoice or superbill.  In some regions, you may want to do this because it is a requirement for insurance purposes.  In those cases, you have 3 options to choose from to add the diagnoses to the patient’s invoice or superbill:

1. Billable Code:  Only add the diagnosis code to the invoice.
2. Billable Text: Only add the name of the diagnosis to the invoice, not the code.
3. Billable Code + Text: Add both the name and the code of the diagnoses to the invoice.

Billing and Status options for Diagnoses.

When you select one of the billable options, the diagnoses will show up itemized in the Express Checkout Dashboard Card, which will allow you or your staff to quickly and easily add it to an invoice or superbill.

Setting the diagnoses status

The status if a diagnoses will help you to better understand whether or not the patient is improving, or worsening.  There are 5 possible diagnosis statuses:

1. Active: Indicates that the diagnoses has been made for the first time if initially added to the chart, or for subsequent charts, that the severity of the concern and symptoms has not changed.
2. Improved: Meant for follow-up visit use, this indicates that the severity of the symptoms has reduced, meaning that the patient is feeling better.
3. Worsened: Meant for follow-up visit use, this indicates that the patient’s symptoms are worsening.
4. Resolved: Meant for follow-up visit use, this indicates that you consider this diagnoses resolved, and the patient cured or stable.
5. Incorrect / Not Applicable:  Meant for follow-up visit use, this indicates that this diagnoses you previously charted was incorrect or no longer applicable to this patient.

Note that marking a diagnoses as resolved will cause this diagnoses to no longer show up in the Client Workspace under the Medical Summary section.

Creating A New Diagnosis

Although OutSmart has over 60,000 diagnoses loaded into our library, there is always the possibility that the diagnosis you want to add to your chart is not available.  In this case, you can create your own.

Once you have added a diagnosis section to your chart, click on the Menu button to the right of the Diagnosis Selection Box, and then select “Create Diagnosis”.  This will open the diagnosis creation window.

Create a new diagnosis.

Enter your new diagnosis name, choose a diagnosis library to add it to, and then enter a diagnosis code if desired.  When you are done, click on “Create Diagnosis”.

Enter the details of your new diagnosis.

Editing and deleting diagnoses

Once a diagnoses has been created, it cannot be deleted from the system, but it can be edited, in case there is a spelling error or something similar.  It’s important to note that editing a diagnoses can have retroactive effects on the same diagnosis in previous charts, if you ever open up that previous chart and re-save it, or if the chart is unlocked.  So it is important, for the consistency and utility of your data, that you do not edit a diagnosis and change it into something completely different.  Editing a diagnoses should only be reserved for instances where you are clarifying it, or adjusting wording or spelling, but not changing it entirely into a different diagnosis.

Note as well that audit-trail records are kept in the system when diagnoses are edited.

To edit a diagnosis, start by adding it to the chart.  Once you have added the diagnosis to the chart, you can then click on the grey menu button to the right of the diagnosis, and select ‘Edit Diagnosis” from the menu.

Editing a diagnosis.